1. Public health expenditure in India has declined from 1.3% of GDP in 1990 to 0.9% in 1999, with the union government contributing only 15% of public health expenditure while states contribute 85%. 2. There are striking regional inequalities in health outcomes and a need to address population stabilization in states with weak demographic indicators. Integrating issues like sanitation, nutrition and drinking water is also needed. 3. The National Rural Health Mission was launched in 2005 to provide universal and equitable access to quality health care, especially focusing on 18 states with weak indicators and infrastructure. It aims to integrate vertical health programs and address social determinants of health.

1. 1
Mrs. Namita Batra Guin
Associate Professor
Dept.. Of Community Health Nursing

2.  Public health expenditure has declined from 1.3% of
GDP in 1990 to 0.9% of GDP in 1999. The Union
Budgetary allocation for health is 1.3% while the State’s
Budgetary allocation is 5.5%.
 Union Government contribution in public health
expenditure is 15% while States contribution is 85%
 Vertical Health and Family Welfare Programmes have
limited functions at operational levels.
 Lack of community ownership of public health
programmes impacts levels of efficiency,
accountability and effectiveness.
 Integration of sanitation, hygiene, nutrition and
drinking water issues is needed in the overall sectoral
approach for Health.
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3.  Striking regional inequalities
 The challenge of Population Stabilization
especially in States with weak demographic
indicators.
 Curative services favour the non-poor.
 Country has to deal with multiple health crisis,
rising cost of health care and mounting
expectations of the people.
 Urgent need was to transform public health
system into accountable, accessible and affordable
system of quality services.
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4.  National rural health mission was launched by
Hon’ble P.M. Dr. Manmohan singh on 12th April 2005.
 Mission seeks to provide universal access to
equittable, affordable and quality health care which is
accountable at the same time responsive to the needs
of people.
 The mission specially focuses on 18 states which have
weak public health indicators and weak infrastructure.
 It is basically a strategy for integrating ongoing vertical
program of Health and Family Welfare and addressing
the issues related to determinants of Health like
sanitation, nutrition and safe drinking water.
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5.  Reduction in child and maternal mortality.
 Universal access to public services for food and nutrition,
sanitation and hygiene and universal access to public health care
services with emphasis on services addressing women’s and
children’s health and universal immunization.
 Prevention and control of communicable and non- communicable
diseases, including locally endemic diseases.
 Access to integrated comprehensive primary health care.
 Revitalize local health traditions and main stream AYUSH.
 Promotion of healthy life styles.
 Population stabilization, gender and demographic balance.
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6.  Reduction in Infant Mortality Rate and Maternal Mortality
Ratio
 Universal immunization against major childhood illnesses
 Prevention and control of communicable and non-
communicable diseases, including locally endemic diseases
 Integrated comprehensive primary healthcare leading to
population stabilization in high fertility districts
 Provision of village level health activists (ASHA) in
underserved villages
 Preparation of Panchayat level Health Action Plan
 Strengthening Sub-centres/PHCs
 Raising CHCs to the level of IPHS
 Institutionalizing District level Management of Health (all
districts)
 Increase utilization of First Referral Units from less than 20%
(2002) to more than 75% by 2010
 Engaging 4,00,000 female Accredited Social Health Activists. 6

7.  Train and enhance capacity of Panchayati Raj
Institutiions(PRIs) to own, control and manage public
health services.
 Promote access to improved healthcare at household
level through the female health activist (ASHA).
 Health Plan for each village through Village Health
Committee of the Panchayat.
 Strengthening sub- center, PHCs through better
staffing and human resource development policy, clear
quality standards, better community support and an
untied fund.
 Provision of 30-50 bedded CHC per lakh population for
improved curative care to a normative standard.
 Preparation and implementation of an inter sector
District Health Plan prepared by the District Health
Mission
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8.  Integrating relevant vertical Health and Family Welfare
programmes at National, State and District levels.
 Technical Support to National, State and District
Health Missions, for Public Health Management.
 Strengthening capacities for data collection, assessment
and review for evidence based planning, monitoring
and supervision.
 Formulation of transparent policies for the deployment
and career development of human resource for health.
 Developing capacities for preventive health care at all
levels for promoting healthy life style, reduction in
consumption of tobacco and alcohol, etc.
 Promoting non – profit sector particularly in
underserved areas 8

9.  Regulation of Private Sector, including the
informal rural practitioners, to ensure quality of
service to citizen.
 Promotion of Public Private Partnerships for
achieving public health goals.
 Mainstreaming AYUSH.
 Reorienting medical education to support rural
health issues including regulation of Medical care
and Medical Ethics.
 Effective and viable risk pooling to provide health
security to the poor by ensuring accessible,
accountable and good quality hospital care.
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10.  Village/large habitat have a female community
health activist-chosen by and accountable to the
panchayat.
 ASHA would act as a bridge between the ANM and the
village and be accountable to the Panchayat.
 ASHA is an honorary volunteer, receiving performance-
based compensation for promoting universal
immunization, referral and escort services for RCH,
construction of household toilets and other healthcare
delivery programs.
 ASHA will make the Village Health Plan alongwith
Anganwadi worker, community workers and ANM
under the leadership of the Panchayat Health Samiti.
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11.  Each sub-centre will have an untied fund for local
action @ Rs. 10,000 per annum. This fund will be
held in joint account of ANM and Panchayat
Sarpanch.
 Supply of essential drugs (allopathic and AYUSH)
to the Sub-centres.
 In case of additional Outlays, MPWs
(Male)/Additional ANMs wherever needed,
sanction of new Sub-centres as per 2001 population
norm, and upgrading existing Sub-centres,
including buildings for Sub-centres functioning in
rented premises will be considered.
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12.  Supply of essential drugs to PHCs
 Provision of 24 hour services in 50% PHCs by
addressing shortage of doctors, especially in high
focus states, through mainstreaming AYUSH
manpower
 Supply of Auto Disabled Syringes for
immunization
 In case of additional Outlays, intensification of
ongoing communicable disease control
programmes, new programmes for control of non-
communicable diseases, and upgradation of 100%
PHCs as FRUs, would be undertaken on the basis of
felt need.
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13.  Operationalizing existing Community Health Centres
(30-50 beds) as 24 Hour First Referral Units(FRUs)
 Codification of new Indian Public Health Standards,
setting norms for infrastructure, staff, equipment,
management etc.
 Promotion of Stake-holders’ Committees (Rogi Kalyan
Samitis) for hospital management
 Developing standards of services and costs in hospital
care
 In case of additional Outlays, creation of new
Community Health Centres (30-50 beds) to meet the
norm of one per 100,000 population, and bearing their
recurring costs for the Mission period could be
considered.
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14.  District Health Plan would be an amalgamation of field
responses through Village Health Plans, State and
National priorities for Health, Water Supply, Sanitation
and Nutrition.
 Health Plans would form the core unit of action
proposed in areas like water supply, sanitation, hygiene
and nutrition. Implementing Departments would
integrate into District Health Mission for monitoring.
 District becomes core unit of planning, budgeting and
implementation.
 Centrally Sponsored Schemes could be
rationalized/modified accordingly in consultation with
states.
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15.  Concept of “ funneling” to district for effective
integration
 All parallel bodies in Health at District and
state level merge into one common “ District
Health Mission” at the District level and the “
State Health Mission” at the state level
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16.  Components of TSC (total sanitation campaign)
include IEC activities, rural sanitary marts, individual
household toilets, women sanitary complex, and
School Sanitation Programme.
 The TSC is implemented through PRIs.
 NRHM proposes district and sub-district
arrangements for Rural Sanitation Programme similar
to the DHM. The DHM would guide activities of
sanitation at district level.
 ASHA is incentivised to promote household toilets by
Mission.
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17.  Strengthening ongoing National Disease Control
Programmes for Malaria, TB, Kala Azar, Filaria,
Blindness & Iodine Deficiency shall be
horizontally integrated under the Mission, for
improved programme delivery.
 New Initiatives would be launched for control of
Non Communicable Diseases.
 Strengthening disease surveillance system at
village level
 Supply of generic drugs (both AYUSH & Allopathic)
for common ailments at village, SC, PHC/CHC
level.
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18.  Since 75% of health services are being currently
provided by the private sector, there is a need to refine
regulation
 Regulation to be transparent and accountable
 Reform of regulatory bodies/creation where necessary
 District Institutional Mechanism for Mission must
have representation of private sector
 Need to develop guidelines for PPP for health sector
 Task Force to improve details/guidelines
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19. Task Force to examine new health financing
mechanisms,including Risk Pooling for Hospital Care as
follows:
 District Health Missions will pay hospitals for services by way
of reimbursement.
 Standardization of services – outpatient, in-patient,
laboratory, surgical interventions- and costs will be done
periodically by a committee of experts in each state.
 A National Expert Group to monitor the standards and give
suitable advise and guidance on protocols and cost
comparisons.
 All existing CHCs to have wage component paid on monthly
basis. Other recurrent costs may be reimbursed for services
rendered from District Health Fund.
 Adequate technical managerial and accounting support to be
provided to DHM in managing risk-pooling and health
security.
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20.  Community Based Health Insurance
Schemes (CBHI) exist/are launched, as part
of the Mission.
 The Central government will provide
subsidies to cover a part of the premiums
for the poor, and monitor the schemes.
 CBHIs will be periodically evaluated for
effective delivery.
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21.  Medical and para-medical education facilities
need to be created in states, based on need
assessment.
 Suggestion for Commission for Excellence in
Health Care (Medical Grants Commission),
National Institution for Public Health
Management etc
 Need for mainstreaming AYUSH
 Task Force to improve guidelines/details.
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23.  Village Health & Sanitation Samiti (at village level
consisting of Panchayat Representative/s, ANM/MPW,
Anganwadi worker, teacher, ASHA, community health
volunteers
 Rogi Kalyan Samiti (or equivalent) for community
management of public hospitals
 District Health Mission (under the leadership of Zila
Parishad with District Health Head as Convener and all
relevant departments, NGOs, private professionals etc
represented on it)
 State Health Mission (Chaired by Chief Minister and co-
chaired by Health Minister and with the State Health
Secretary as Convener- representation of related
departments, NGOs, private professionals etc)
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24.  Integration of Departments of Health and Family Welfare,
GoI
 National Mission Steering Group chaired by HFM with Dy.
Chairman Planning Commission, Ministers of Panchayat
Raj, Rural development and HRD and public health
professionals. Secretary HFW as Convener
 Empowered Programme Committee chaired by Secretary
HFW
 Standing Mentoring Group for ASHA
 Task Forces for Selected Tasks (time-bound)
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25. 25
National Steering Group
Mission Steering Group
Empowered Programme Committee
State Health Mission
District Health Mission ------------Rogi Kalyan Samitis
Village Health
Committee
Village Health
Committee
Village Health
Committee
Mission Directorate
ORGANOGRAM
Panchayat

26.  To include reorientation into public health
management
 Reposition existing health resource institutions
 Involve NGOs as resource organisations
 Improved Health Information System
 Support required mostly at District and below district
level. Also at state and national level
 Technical support National Level and State level public
health institutions need to be created in government,
non government and private sector
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27.  The Mission covers the entire country. GoI would
provide funding for key components in these 18 high
focus States. Other States would fund some
interventions like ASHA, PMU, upgradation of
SC/PHC/CHC through Integrated Finance Envelope.
 States would project operational modalities in their
State Action Plans, to be decided in consultation with
the National Mission Steering Group.
 NRHM would prioritize funding for addressing inter-
state and intra-district disparities in terms of health
infrastructure and indicators.
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28.  The Mission envisages the following roles for PRIs:
 ASHAs would be selected by and be accountable to
the Village Panchayat.
 The Village Health Committee would prepare the
Village Health Plan, and promote intersectoral
integration.
 The untied fund at Sub-centres to be deposited in a
Bank Account, jointly operated by ANM and
Sarpanch. District Health Mission to be led by the
Zila Parishad. The DHM would also guide
activities of sanitation.
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29.  PRI involvement in Rogi Kalyan Samitis for good
hospital management.
 Training to members of PRIs.
 Making available health related databases to all
stakeholders, including Panchayats at all levels.
 States to indicate in their MoUs their commitment
for devolution of funds and programmes to PRIs.
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30.  Role of the NGOs for the Mission is as
envisaged as follows:
In institutional arrangements
Standing Mentoring Group for ASHA
Member of Task Forces
Provision of Training, BCC and Technical
Support for ASHAs/DHM
Health Resource Organizations
Service delivery for identified population
groups on select themes
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31.  The Mission envisages an additionality of 30% over
existing Annual Budgetary Outlays, every year, to fulfill
the mandate of the National Common Minimum
Programme to raise the Outlays for Public Health from
0.9% of GDP to 2-3% of GDP.
 The States are expected to raise their contributions to
Public Health Budget by minimum 10% p.a. to support
the Mission activities.
 Funds are released to States through SCOVA, largely in
the form of Financial Envelopes, with weightage to 18
high focus States.
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32.  Health MIS is developed upto CHC level and is web-enabled for
citizen scrutiny
 Annual District Reports on People’s Health (to be prepared by
Govt/NGO collaboration)
 State and National Reports on People’s Health to be tabled in
Assemblies, Parliament
 Sub Centres to Report on performance to Panchayats, Hospitals to
Rogi Kalyan Samitis and District Health Mission to Zila Parishad.
 External evaluation through professional bodies/NGOs.
 Mid- course reviews are also done as a part of evaluation.
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33.  Indian Public Health Standards are a set of
standards envisaged to improve the quality of
health care delivery in the country under the
National Rural Health Mission.
 A Task Group under Director General of Health
Services was constituted to recommend the
Standards. The IPHS is based on its
recommendation.
 At present these standards are being applied only
to the Community Health Centres (CHCs).
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34.  Improvement in the availability of specialist services in the
CHCs by ensuring availability of all the sanctioned
specialists.
 Strengthening support staff, by recommending a Public
Health Nurse and an ANM in all these Centres, in addition
to the existing staff.
 Norms for infrastructure, equipment, laboratory, Blood
storage facilities, and drugs have been formulated.
 Guidelines for management of routine and emergency
cases under National Health programmes are being
provided to all CHCs
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36.  INCREASED FUNDING SUPPORT TO STATES
UNDER NRHM
 Over Rs 71,000 crore provided to states under the
NRHM for health system strengthening, reproductive,
maternal, newborn, child and adolescent health and
control of diseases.
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37.  MATERNAL HEALTH
 MMR declined from 254 to 178
 India very close to achieving MDG goal of MMR of 150 by
2015.
 More than 01 crore women every year received cash
incentives under JSY.
 Free delivery including C-section in govt. hospitals and free
healthcare for mothers and newborns under Janani Shishu
Suraksha Karyakaram (JSSK).
 JSSK free entitlements also include:
 Free drugs and consumables
 Free diagnostics
 Free diet
 Free blood wherever required.
 Free transport from home to institution, between facilities in case
of referrals and drop back home.
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38.  MATERNAL HEALTH
 JSSK expanded to cover complications during antenatal and
postnatal period and infants upto 1 year of age.
 Rs 5,500 allocated to states since JSSK launched.
 Institutional deliveries have risen from 47% to over 84%.
 Over 3 crore women protected with IUCD.
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39.  CHILD HEALTH
 Rashtriya Bal Swasthya Karyakram (RBSK) launched in Feb
2013 for screening and free treatment targeting 27crore
children between 0-18years of age.
 More than 5core children already screened under RBSK 12.5
lakh given free referral services including surgeries at tertiary
level.
 Routine immunization coverage improved substantially from
60% to 85%.
 12crore children vaccinated with 2nd dose of Measles
introduced in 2010, moving towards the elimination in 2020.
 Child deaths due to measles came down from 1 lakh to
30,000 per year
 Neonatal tetanus eliminated in 18states.
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40.  CHILD HEALTH
 More than 1.5 crore children vaccinated with newly
intoduced Pentavalent vaccine to protect them from Hib
meningitis and pneumonia.
 Hep. B vaccination expanded to entire country in 2010.
 JE vaccination expanded from 113 districts in 15 states to 177
districts in 19 states in 2013.
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41.  Community Participation
 Number of ASHA providing home based mother and
newborn care, counselling newly married couples, and
distributing contraceptives at door steps has risen to nearly
9Lakh.
 More than 5lakh village health sanitation and nutrition
committees created.
 More than Rs. 6000 core sanctioned to 31,000 new Rogi
kalyan samitis (RKS) set up.
 Several new cash incentives for ASHAs introduced.
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42.  Adolescent
 Rashtriya Kishore Swasthya Karyakram (RKSK) launched to
reach out to 25 crore adolescent.
 Number of adolescent Reproductive & Sexual Health
(ARSH) clinics increased from3,356 to 6,302.
 4 crore packets of sanitary napkins Freedays distributed free
to nearly 2 crore adolescent girls.
 Weekly Iron and Folic acid Supplementation for adolescents
launched to benefit more than 12 crore adolescent.
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43.  Improved infrastructure and Human resources
 470 MCH wings under construction with 30,000 bed
capacity at a cost of Rs. 4,000 crore.
 Special Newborn care units increased from 184 to 507.
 Nutritional rehabilitation centres have increased from 180 to
872.
 More than 1.5 lakh severely malnourished children treated in
2013.
 Free drugs Service Initiative launched .
 National Urban Health Mission launched with special focus
on urban poor, to cover approx 22 crore people.
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44.  Improved infrastructure and Human resources
 Patient access to OPD increased.
 Annual IPD increased from 2.15 to 4.26 crore.
 Institutional deliveries increased.
 Number of ambulances increased from 5,000 to over 20,000.
 Number of Dial 108 ambulances increased.
 Vehicles empanelled for transporting pregnant women to public
health institutions for delivery increased from 1,324 to 4,769.
 2,062 mobile medical units operationalized as “National Mobile
Medical Unit Service”
 Web based Maternal and child tracking system (MCTS)
introduced to track every pregnant women and child upto 5 years
of age and ensure regular service delivery. Over ten crore pregnant
women and children registered till now.
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